Posted on
1/02/13

Leslie,
a 49 year-old woman with 2 teenage boys, visited her local pharmacy to refill
her monthly prescription of hydrocodone, which she had been taking for severe
osteoarthritis. Noting that Leslie was more than a week early for a refill, the
pharmacist checked her file, which showed a pattern of increasingly early
refills over the previous 5 months. In response to the pharmacist’s questions
about adherence, Leslie proudly explained that she takes her medicine as
prescribed, never deviating from her doctor’s instructions. Thinking out loud
about why her pills had not lasted through the entire month, Leslie revealed
that one of her sons had recently been skipping school and socializing with
older boys who had been in trouble with the law. When the pharmacist asked
about access to the pills, Leslie answered that she kept all her medicines in
an unlocked cabinet in her house’s only bathroom. Raising the possibility that
Leslie’s son or his friends might be diverting the hydrocodone pills, the
pharmacist suggested that she keep them in a more secure place, and Leslie
agreed.

Discussion

Over
the last 2 decades, prescription medication misuse, abuse, and diversion have
become serious public health problems in the US. Prescription pain relievers
are among the most commonly misused, abused, and diverted medications. According
to the Centers for Disease Control and Prevention, the quantity of prescription
pain relievers sold to pharmacies, hospitals, and doctors’ offices was 4 times
larger in 2010 than in 1999.1 The 2011 National Survey on Drug Use
and Health (NSDUH) reported that an estimated 4.5 million Americans over age 12
were current nonmedical users of pain relievers.2 Of these survey
respondents, the majority reported that they obtained the medications from a
friend or relative for free.2 Other illicit methods for obtaining prescription
medications include theft from legitimate patients or pharmacy personnel,
doctor shopping, and falsifying prescriptions. As front-line workers in the
health care system, pharmacists are well situated to help identify and combat
prescription drug abuse and diversion.

The
most commonly abused prescription drugs include opioids, such as codeine and
oxycodone; central nervous system depressants, such as barbiturates and
benzodiazepines; and stimulants, such as dextroamphetamine and methylphenidate.3
Adolescents are especially vulnerable for drug abuse. The 2011 NSDUH
survey reported that among 12- to 17-year-olds, the rate of past-year substance
dependence or abuse was 6.9%, and the rate of past-year nonmedical pain
reliever use was 5.9%.2 Another group at relatively high risk for
prescription drug misuse and abuse is the elderly.

According
to Drug Enforcement Administration (DEA) regulations, pharmacists are
responsible for protecting their practices against drug diversion. As stated in
the DEA Code of Federal Regulations Section 1306.04, “the responsibility for
the proper prescribing and dispensing of controlled substances is upon the
prescribing practitioner, but a corresponding responsibility rests with the
pharmacist who fills the prescription.”4 This regulation also indicates
that a person who knowingly fills a prescription for illegitimate use “shall be
subject to the penalties provided for violations of the provisions of law
relating to controlled substances.” Further, pharmacists are held accountable
by state licensing boards that can conduct site inspections and audit pharmacy
records. Penalties for infractions include fines, probations and, in some cases,
loss of pharmacy licenses. To guard against these penalties and to contribute
to the vital societal mission to resolve a serious public health issue,
pharmacists must be aware of tactics used to divert prescription drugs.
Moreover, they must establish safeguards against diversion, remaining vigilant
in its prevention. According to the DEA Pharmacist’s Manual, these efforts
include contacting local police when the pharmacist suspects cases of
prescription drug abuse or diversion.5 In such cases, pharmacists
can also rely on state prescription drug monitoring programs that have recently
been implemented throughout the country.

An
important role that pharmacists play in preventing medication abuse and
diversion is recognizing behaviors that indicate inappropriate drug-related
behaviors. In addition to doctor shopping and falsifying prescriptions, people
who abuse prescription drugs demonstrate several other aberrant behaviors,
including unauthorized self-increased doses, drug hoarding, requesting specific
drugs, and aggressively demanding higher doses.6 Behaviors that are
more predictive of drug abuse, misuse, and diversion include forging
prescriptions, stealing drugs, using alternative methods of ingestion such as
snorting or injecting oral drugs, claiming recurring prescription losses, and
using a number of illicit drugs simultaneously.6 However, these
behaviors do not automatically indicate drug misuse or abuse; thus, each
patient must be assessed on an individual basis.

This
case study points to another important role of the pharmacist in the battle
against prescription drug abuse and diversion: patient education. By providing
patients with clear information on how to take medications properly, on side
effects, and on possible drug interactions, the pharmacist can help prevent
medication errors and reduce unintentional drug abuse. Also, it is important to
educate patients about the possibility of prescription drug abuse and the best
ways to store medications securely.

Reducing
prescription drug abuse and its societal harms is a national health care
priority in the US.7 Because the pharmacist often interacts with
patients more extensively than do physicians or other health care
professionals, he or she is frequently best situated to provide the first-line
defense against this serious problem. By remaining aware of the problem and
developing protocols to prevent abuse and diversion, pharmacists can contribute
meaningfully to the important mission at hand.